CITY OF NAMPA NOTICE OF CLAIM

Deborah Bishop, City Clerk

In compliance with applicable sections of Title 6, Chapter 9, Idaho Code, the undersigned hereby presents a claim against the City of Nampa, Idaho, for damages arising out of an occurrence, which happened as follows:

Click the link below if you would prefer to print and complete a paper claim form

4. Witnesses:

Name

Address

Phone Number

(Attach all bills or other substantiating information verifying the amount of your claim)

6. Bodily injury

(Describe the extent of your injury, your attending physician, place of emergency treatment and any other pertinent information)

7. Property damage

(Describe property and vehicle damage)

8. Claimant Information

First Name*

Last Name*

Contact Phone

Email Address

Address1*

Address2

City*

State*

Zip*

9. Additional Parties Involved

(Please add the name, address and phone number for any additional parties involved)

10. Former Address

(Required if at current address less than six months)

Address1

Address2

City

State

Zip

11. Supporting Documentation

Upload all supporting documentation

12. eSignature

By checking the box and entering your information below, you hereby declare, under penalties of perjury, that you are authorized to submit the information in this form and to the best of your knowledge, it is true, correct and complete and your authorize it to be processed.